A ballot for possible strike action by junior doctors has opened for the first time following union criticism of a last-ditch pay offer by the Health Secretary as "fundamentally flawed".
Jeremy Hunt was accused by doctors' representatives of "megaphone diplomacy" after he announced a proposed new contract that would see trainees' basic pay rise by 11% and maximum working hours fall from 91 to 72.
The British Medical Association (BMA) begun issuing papers to members on Thursday and doctors will have until Wednesday November 18 to respond to two questions: whether they are prepared to take part in a strike and whether they are prepared to take industrial action short of striking.
The BMA has proposed to stage emergency care-only action in the first instance, with junior doctors providing the same level of service as they would do on Christmas Day.
But there is the possibility of all trainees in England withdrawing their labour, the union said.
BMA junior doctors committee chairman Johann Malawana wrote to trainees on Wednesday, saying: "In short, there is nothing new in what the Government is putting forward. That is why our decision to ballot our members still stands.
"So, tomorrow, the first ever juniors-only ballot for industrial action will open. The uniqueness underlines the severity of the situation in which we currently find ourselves -- the situation that the Government has forced us into."
The Health Secretary said earlier his door was open to the BMA but blamed the doctors' union for refusing to return to the negotiating table.
Ministers want to scrap the complicated "banding" system, which builds up earnings based on responsibilities, hours worked and how often they are on call.
But they are proposing to offset those sums with the hike of around 11% in basic salary, together with supplements such as for being on call, working out of hours, and premiums for working in disciplines with staff shortages.
Flexible pay premiums would be applied to more specialities than just general practice and A&E care, with acute medical ward staff and psychiatrists benefiting.
Mr Hunt claimed the revised proposals would mean pay increasing for 75% of doctors.
He defended the new offer, saying: "Any doctor working within the legal maximum safe hours will not be worse off. There are about 500 doctors who are working outside the legal safe hours and for those doctors we think the right thing to do is actually restrict the hours they work, so they are giving safe care for patients.
"One of the important things about the proposals we are making today is that they will make care safer for patients.
Mr Hunt added the plans were aimed at creating a truly seven-day-a-week NHS and insisted the threat to unilaterally impose the contract was necessary.
But the BMA said there could be no meaningful negotiation over the new proposals unless Mr Hunt withdrew his threat to impose the new contract on medics without agreement.
And they asked for assurance any new contract would include "proper recognition of unsocial hours as premium time", those working unsocial hours would not be disadvantaged and a guarantee "all of the hours worked will be paid".